A Market for Transplant Organs?

Clark Wolf, Iowa State University Director of Bioethics
jwcwolf@iastate.edu

As I write this sentence, there are more than 90,000 people in the United States waiting for transplant organs.(1)  About 66,000 of them are waiting for kidneys.(2)  By the time you read this sentence, the number will be much larger because people are added to the list at a faster rate than they leave it.  Some people leave the list when they receive a transplant, but many more will leave the list because they will die waiting for one.  Every year, between four and six thousand people in the United States die waiting in vain to receive a transplant.  Each day about fourteen people die in the United States because they were unable to acquire the organ that would have saved their lives.

Where might the needed transplant organs come from?  Some transplant organs, like hearts, only become available at the death of the donor.  Others, like kidneys, can be donated by living donors.  As long as one’s remaining kidney is functioning normally, a person can live as well with one as with two.  Donation does increase the donor’s risk, however.  In the event that a donor herself later develops kidney disease, she may have given away what would have saved her life.  Every year, more than 10,000 people die whose organs would be appropriate for transplant.  Of these, only about half donate their organs.  If a larger proportion of people could be encouraged to participate in the pool for transplant organs, the problem of scarcity might be solved and lives saved.

This problem is no hypothetical philosophical puzzle.  If you are yourself on the list waiting for a transplant or if someone you know or love is waiting, the fact that most people on the list will die waiting is bitter truth.  The bitterness is stronger since those deaths may be unnecessary.  Many economists and bioethicists urge that we could increase the supply of transplant organs by opening a legal, regulated market for them.(3)  In the case of organs like kidneys, which can be given by living donors, this could involve a direct market linking donors who would sell their organs to the recipients who would buy them.  Arrangements could also be made for the post-mortem sale of transplant organs.  Donors could arrange for payment to be made to their families and heirs at the time of death.  In this way, organ donation could become an additional life insurance policy benefiting bereaved families who may need resources to help compensate for lost income due to a wage-earner’s death.  For some families, such a benefit could be very important indeed, so this might provide a powerful incentive for people whose organs would otherwise be buried with them.  Such arrangements benefit the donors and their families, who receive a check.  As long as they are appropriately protected and informed of the risks involved (for live donation), their decision to participate in this market would merit our respect.  Unless we have excellent reason to interfere with such a decision, we should let people make such choices for themselves.  The benefit to organ recipients, in many cases, would be their lives. 

However, the National Academy Institute of Medicine urges that we should resist such suggestions.  In a recent report titled "Organ Donation: Opportunities for Action," they write:

“Financial incentives [for transplant organs] might disproportionately affect the poor or other marginalized groups, and might also cause a drop in donations for altruistic reasons if people see donated organs as goods with a certain market value.  And nonfinancial incentives, such as reciprocity agreements, might disadvantage those who are less informed about organ donation and therefore increase existing social inequality.”(1)

The concern that incentives for organ donation might victimize the poor and uninformed is a concern of justice, a high moral priority indeed.  However, the present system may also facilitate the exploitation of the poor.  There is an active international market linking poor organ donors in poor countries with wealthy recipients from the United States and elsewhere.(4)  Because this market is illegal, there are no protections to insure that donors are appropriately informed or well treated.  Legalization would at least make it possible to regulate this market to protect the donors.  There is good reason to believe that we could better protect organ donors if it were legal to offer incentives for contribution.

For many people, the idea that people might sell their own organs for transplant inspires an almost instinctive disgust and repugnance.  This is an authentic moral response, and we should take it seriously.  We should analyze and understand the source of such attitudes when we experience them.  But if we cannot articulate the source in reasons and arguments, we should be hesitant to use that instinctive response as an excuse to retain a system that condemns so many people to unnecessary death.  The International Forum for Transplant Ethics recently wrote:  "The well-known shortage of kidneys for transplantation causes much suffering and death. If we are to deny treatment to the suffering and dying, we need better reasons than our own feelings of disgust." (5)


Sources and Further Reading:

1.  Institute of Medicine of the National Academies [IOM]. 2006. Organ Donation: Opportunities for Action.  Washington DC: National Academies Press.

2.  Postrel, S. “’Unfair’ Kidney Donations.” Forbes Magazine. 6 June 2006.

3.  Boudreaux, D. J. and Pritchard, A.C. 1999.  “Organ Donation: Saving Lives through Incentives.”  Viewpoint on Public Issues.  Macinac Center for Public Policy: Midland MI.  99(34).

4. Rother, L. “Tracking the Sale of a Kidney on a Path of Poverty and Hope.”  New York Times, 23 May 2004.

5.  Satel, Sally. “Death’s Waiting List.”  New York Times, 15 May 2006.

Alsever, J. “Basking on the Beach, or Maybe on the Operating Table.”  New York Times 15 October 2006.

Morley, M.T. 2003.  "Increasing the Supply of Organs for Transplantation Through Paired Organ Exchange," Yale Law & Policy Review (Winter 2003): 221.

Roth, A., Sonmez, T. and Unver, M.U. 2004.  “Kidney Exchange.”   Quarterly Journal of Economics.  May 04.  pp. 457-488.

Thursday, November 16, ISU Lectures Series
8:00 p.m., Sun Room, Memorial Union, "The Melting Ice Cellar,"  Patricia Cochran, an Inupiat Eskimo born and raised in Nome, serves as executive director of the Alaska Native Science Commission (ANSC).  Information: http://www.nativescience.org/html/cochran.html

Friday, November 17, Natural Resource Ecology and Management Seminar
10:00 a.m., E164 Lagomarcino Hall, "Global Warming and Traditional Ecological Knowledge".  Patricia Longley-Cochran of the Alaska Native Science Commission will give this follow up talk to her presentation the night before.  Information: http://www.nrem.iastate.edu/news/seminar.html.

Monday, November 20, Iowa Organic Conference
8:00 a.m. - 6:00 p.m., Iowa State Scheman Building, Ames.  Forums, trade show, all-organic locally produced lunch.  To register online:  www.usc.iastate.edu/mnet/organic06/home.html.

**No events scheduled the week of November 20th to the 26th: University
Thanksgiving Break.**